Difficulty: Medium
Average Score: 88%
Simulated
Passage / Scenario
Nurse NotesToday, 0800:
Urgent Care
Client reports feeling very anxious and states they have a terrible headache. The client is diaphoretic and rates headache as 9 on a 0 to 10 numeric pain scale. Client was evaluated by provider and was transferred by emergency medical services to the emergency department
Today, 0900
Emergency Department
The client states ÔÇ£I went to urgent care this morning because had a terrible headache. I thought it might be a migraine. They told me my blood pressure was too high, so they sent me here" Client reports having sinus issues and taking over the counter decongestants for the past few days. Client also states, "last week my provider changed my medication from paroxetine to phenelzine and my depression is decreasing.ÔÇØ
Client appears nous restless, Breath sounds clear and equal.
Heart sounds S1, S2, no murmur. Skin is warm to touch, very diaphoretic
Client reports headache as a 10 on a 0 to 10 numeric pain scale
Vital Signs
Today, 0800
Urgent Care
Blood Pressure: 191/92 mmHg
Heart Rate: 104/min
Respiratory Rate: 18/min
Temperature: 39.2┬░C (1026┬░F)
Oxygen saturation 95% on room air
Today, 0900:
Blood Pressure 197/99mmHg
Heart Rate: 108/min
Respiratory Rate: 20
Temperature: 39.6"(103.2┬░F)
Oxygen saturation: 93% on room air
Complete the following sentence by using the list of options. The nurse should plan to administer ____ and ____.
Correct answer
A,B
Rationale
Action to Take: A, B; Potential Condition: Not specified; Parameter to Monitor: Not specified.
Rationale: Intravenous phentolamine is used to treat hypertensive crisis due to a pheochromocytoma, while applying a cooling blanket helps manage hyperthermia. These actions are appropriate when managing a hypertensive crisis or hyperthermia. Oral benztropine and oral valbenazine are used for movement disorders, not for the conditions mentioned. Intravenous diphenhydramine is used for allergic reactions, not for the conditions described. Placing the client on suicide precautions and checking the absolute neutrophil count are unrelated to the context of administering phentolamine and applying a cooling blanket.
Rationale: Intravenous phentolamine is used to treat hypertensive crisis due to a pheochromocytoma, while applying a cooling blanket helps manage hyperthermia. These actions are appropriate when managing a hypertensive crisis or hyperthermia. Oral benztropine and oral valbenazine are used for movement disorders, not for the conditions mentioned. Intravenous diphenhydramine is used for allergic reactions, not for the conditions described. Placing the client on suicide precautions and checking the absolute neutrophil count are unrelated to the context of administering phentolamine and applying a cooling blanket.